Things Don’t Always Go According To The Plan

We were sent for an “External Hemorrhage” which is usually either a dialysis shunt rupture or a varicose vein rupture. 99% of the time the bleed is controlled by the BLS guys before we get there and we’re cancelled.

Not this time, though. CAD update was “bleeding from neck”. WTF?

BLS crew arrives and gives no update. We’re waiting for the cancellation that never comes.

As we walked towards the house the BLS crew update is, “Bring a scoop stretcher up with you.”

Oh-oh.

We grabbed our gear and the scoop and trudged up the stairs into the house. A guy standing in the front hall said, “Go up stairs, turn left, go up the next set of stairs, turn right and go down the hall. Hmm, it’s a two story house, which means that we’re going to the attic. Which has a small apartment added on with an equally small stairway of course. Narrow and with a right angle about half way down. If this patient weighs more than about 100 pounds, it’s not going to be fun getting him down.

Question #1. Why do very sick people always gravitate to the top floor? Question #2. Is it that they know they’re dying and figure that by going to the top floor they’ll be closer to heaven? If I ever figure that one out, my life will be complete. One of life’s imponderables I guess.

We got upstairs and found the BLS crew, FD, and of course the patient. Who is lying on the floor surrounded by blood. Lot’s of bright red blood with lots of clots. I’m guesstimating about 500 cc’s of blood. Damn. He weighed about 11o pounds more or less. At least we had that going for us.

“Does he have a pressure?”

“Yeah, about 90/p.”

Splendid. Which as I’ve mentioned before is what my mother used to say when things were anything but.

“Well, let’s get him on the scoop and get down to the ambulance.”

The BLS crew had the bleeding controlled with direct pressure and a dressing.

While we were securing the patient to the scoop, we got the story. 60ish year old manwith cancer of everything. Shunt in his neck, feeding tube, IV port in his chest, suprapubic urinary catheter. Oh, and a tracheostomy. I have to mention that because it becomes crucial later on. Full code, of course. No mention of DNR or hospice. I wonder what idiot at the hospital forgot to have that conversation.

We moved the patient downstairs and out of the house. On the front porch my partner asks me if we are going to our ambulance or the BLS one. I look at the BLS ambulance which is right in front of the house and then down the street half a block past the fire truck to our ambulance.

“Their ambulance.”

This turned out to be a very wise decision, as you’ll soon see.

The patient was conscious, he was alert, he was following commands. He was also a train wreck, but a manageable one we figured. Once we got the past the part where he had a terminal illness, he was doing OK.

Our plan was to get him in the ambulance, do the necessary monitoring, start an IV if possible and transport to his hospital of choice.

Off we went to the hospital and I prepped what I thought was a decent vein for the IV. My partner got on the med radio to call the patient’s hospital of choice and that’s when the shit show commenced.

First the radio wasn’t transmitting. While my partner was trouble shooting that, whatever process had caused the patient to start bleeding externally now caused the patient to bleed internally into his tracheostomy. (Later opinion from the hospital was that the cancer had eroded the innominate artery.) Which he declared to us by coughing blood up out of his stoma and all over the ambulance. And my partner. Note that that was the BLS truck. It must have been my wily old paramedic spidey sense that told me to go to the BLS ambulance.

Fuck!

My partner grabbed a suction catheter and started suctioning bright red bubbly blood out of the airway.

Then, just in case we hadn’t got the point that the call was going to hell, blood started to come out of his mouth and nose too.

The Shit Show had just been upgraded to a Goat Screw.

I grabbed the portable suction while I yelled to the EMT driving that we needed to divert to the closest facility, which was only about three minutes away. Uncontrollable bleeding + unmanageable airway = Closest hospital.

Through all of this the patient remained conscious, breathing, and aware of the fact that he was dying right in front of us.

I don’t think I’ll ever forget the look in his eyes. Mine probably had a very similar look and I know that my partner’s did as well. It’s pretty awful to watch someone dying helplessly.

My partner tried the med radio again with no luck.

I called dispatch on my portable radio and told the dispatcher to call the hospital on the phone and tell them we were bringing in a patient bleeding from his trach with an uncontrollable airway.

The patient coughed up more blood, covering my partner again. I, being the experienced provider that I am, didn’t get a drop on me. Comes with experience, I guess.

We got to the hospital in short order and transferred the patient over to the staff. Per usual for this joint, they didn’t have the full code team waiting for us because per usual they didn’t believe that we were telling the truth.

As soon as they got a look at the patient and pooped their drawers, much overhead paging of the resuscitation team started.

We cleaned up and watched for a while as the patient did his best to die and the hospital staff did their best to keep him from dying. He was in cardiac arrest for a while, but they got him back. They managed to intubate him, which we never even attempted to do being so busy just trying to keep him from drowning in his own blood. It helps to have doctors, nurses, Xray techs, respiratory techs, and lots of equipment. And plenty of working room of course.

I have no doubt that the patient finally beat them in the end and died.

Poor bastard.

UPATE: From a FB commenter,

Stephen Husak I call bullcrap story. You say he was in full code but yet when you were carrying him out of the house he was concious and alert and following commands while you were deciding ambulances. Then he was back in full code when you diverted.

The person who corrected you had it right, buddy. In all my years in EMS, I’ve never seen a “partial” cardiac arrest. Cardiac arrest is the term that I use for cardiac arrest. Nurseys use “code” for cardiac arrest, because they don’t know better.

Another UPDATE: Apparently the term “Full Code” is causing some confusion. Around here, and I’ve heard the term used in other parts of the country as well, “Full Code” means that the patient or their family, wants all resuscitative measures taken, no matter how futile. It has nothing to do with whether the patient is in cardiac arrest or not. I’ve always thought the term “Full cardiac arrest” was silly because, as I note above, I’ve never seen a patient in “Partial cardiac arrest”. Nor has anyone ever been able to explain to me what a “partial” cardiac arrest might be.

Sigh…just when I get to missing being on a truck and not teaching newbies all the time…I read such,

We got to the hospital in short order and transferred the patient over to the staff. Per usual for this joint, they didn’t have the full code team waiting for us because per usual they didn’t believe that we were telling the truth.

And it reminds me of the hospital I used to work for?

Well that plus the fact even sitting here I have Ibuprofen time back and leg pain which seems to remind me why they won’t let me work on the truck at the current service I teach for…sigh..

Sadly, this is all too common. Not all that long ago I was notifying them of a serious case that needed to be in the resuscitation room. The nurse replied, “We’ll decide that when we see you at triage.”
I thanked him and told him we’d just divert to a different hospital where they pay attention to our reports. Magically, we were directed immediately to the resuscitation room.

There isn’t any. For some reason that I’ve never understood most hospitals and EMS systems use “Code” to mean cardiac arrest. It’s very common for patients in their advanced directives (if they have them) to specify that they want intubation, no intubation, CPR or no CPR, drugs or no drugs, etc… A patient who wants everything done is known as a “full code” meaning that they want everything done for them, even in the face of futility. Personally, I think that some nursing homes hide the DNR forms so that we’ll have to transport, but that’s a suspicion only. In this case, the patient was at home, but from our brief conversation with the family there seemed to be no end of life planning at all. So, we were committed to resuscitating him no matter what.

In many hospitals (such as the one I work for) different color codes/names are used to designate different types of in-hospital emergencies. For example, “Code Magenta” might mean “Pediatric Cardiac Arrest” whereas “Code Cyan” means “Adult Cardiac Arrest.” I daresay that might be where the term “code” orginated, but I could be wrong on this, and TOTW is more than welcome to correct me on this.

True indeed. Though I remember a time (sometime in the 90s perhaps?) when hospitals were trying to cut back on the word “CODE” because it freaked out the visitors (who realized “CODE” meant in-hospital emergency of some sort). So, many places changed code to “Mr.” (“Mr. Red” for a fire, “Mr. Blue” for an arrest, etc.). Funny, it didn’t take long for the public to figure it out and everyone went back to “CODE”.

Question #1. Why do very sick people always gravitate to the top floor?

Here’s my theory: Most bedrooms are located on the top floors. When one is sick, they usually seek the comfort of their own bedroom. (Unless you’re in my family, where your puking self gets confied to the nearest bathroom until your body manages to quelll all “return to sender” attempts.) Hell, even at that level of sickness, we still might manage to crawl down steps if they promise REAAAAALLY good drugs.

Then again, the last time an ambulance was called on me, I was practically sitting in the foyer and they only had to take my buck-something body down two steps…

Experience of late is that those who call and live on the first floor are perfectly able to walk and more than willing. Those on the second are reluctant, however can be conned, er, coached into walking. Those that live on the third floor are either 400+ pounds, true invalid, or absolutely unable to be convinced that they are perfectly OK to walk, their runny nose not withstanding. Or, they are the true trainwreck of a patient that has to be carried, and the stairwells are narrow….

On another note, I am with CombatDoc…that Goat Screw update is priceless…

If I had a medic patch to me that they were coming in with profuse bleeding from a trach I would do a few things quickly.

First, I would put some of those little Tyvek booties on my nice shoes.

Next, I’d be setting up 2 suctions, getting a #5 tube ready to shove down the trach, a #7 for a regular intubation if that didn’t work out, and I would make sure the secretary had the cell phone of the cardiothoracic surgeon, ready to dial. Probably put a diaper on myself, just in case…

And I bet I know which hospital and ED nurses you had to deal with. Same ones who dumped all over me the time I brought a patient that was an arrest save in only to find out from the staff that said patient had a DNR. When we asked at the facility we brought the patient out of, they denied it.

The original hospital was one that you are familiar with, if you know what I mean. Think baseball. 😉 The other hospital shall remain nameless, but it’s one that you’ll see the Green Machine’s units at frequently. Further Affiant sayeth not.

I ran a call very similar to this a few weeks ago. We got dispatched for a patient post-syncopal episode. Apparently he had passed out three hours before at the store, and his landlord called 9-1-1 because he looked like shit. When we got there he was white as a sheet, ice cold skin, and with absent radial pulses. We hooked him up to the monitor and it kept alternating between STEMI alert and LBBB as I recall. We ran him in hot and had over 800mL of fluid into him by the time we got him through the doors and his pressure never spiked above 74 systolic. The look in his eyes is what I remember most. They were that clear, light ice blue, and they were wide. You could just see the fear in them, even though he kept telling us he wasn’t. They hung levophed and still never got him out of the 70s. He died two hours later. They ruled it cardiogenic shock, but I never did hear what the cause of it was.

I think that’s probably one of those calls I won’t forget, and just because of the look in that man’s eyes while he was dying in front of me.

All About Me

After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it?
I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs.
I still write about EMS, but I'm adding more and more non EMS subject matter.
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